Speaking at the recent symposium on health equity at Cleveland Clinic, Chirag Shah, MD, professor of Radiation Oncology, co-director of the Comprehensive Breast Program, and director of breast radiation oncology and of clinical research at Cleveland Clinic Cancer Center, described the work his colleagues and he have been doing to develop a low-cost program for breast cancer screening among unhoused women in the Cleveland area. Shah began by describing the event that first inspired his desire to do this kind of work, which took place when he was a young man. His father had come to the United States as an immigrant with no resources and, with the support of others, managed to build a life for his family and to make a living by pouring concrete in the construction industry. One day, his father was unwell, and he asked Shah to deliver food packages to a group of low-income families. Confused by this request, Shah discovered that for the previous 30 years, his father had been volunteering for the Salvation Army and delivering food to those in need. In his modesty, his father had never mentioned this involvement to his family.
The experience set Shah on a career path that led him to Cleveland Clinic, where his colleagues and he are currently working to address the early death and elevated cancer rates noted among the homeless. Citing study data from his colleague Jeremy Weleff, DO, Shah noted that the average life expectancy of a person experiencing homelessness is approximately 3 decades shorter than that of the average person with housing. Additionally, data from a retrospective cohort study within the Northeast Ohio Cohort for Atherosclerotic Risk Estimation Learning Health Registry showed that among adults with metastatic cancer experiencing homelessness and housing insecurity, the 5-year all-cause mortality hazard ratio was 6.62 (95% CI, 3.99-10.97)— that is, there was a nearly 7-fold increased risk of death.
The need to identify and treat cancer among these underserved patients was highlighted in results from a study conducted by Cleveland Clinic faculty, including Shah, that were presented at the 2022 American Society of Clinical Oncology Annual Meeting. The study found significantly lower rates of breast cancer screening among women experiencing homelessness compared with the overall population (P < .00001). Risk factors for not being screened included tobacco use, illicit drug use, not having an assigned primary care physician, and not having health insurance.1 Shah emphasized the importance of identifying barriers to care access and developing actionable and affordable strategies for overcoming them. He underscored that any successful program would have to endure over time, as opposed to programs that spring up and disappear after a year or 2. Shah described the HOPE program, a pilot project at Cleveland Clinic that aimed to address oncologic disparity among women experiencing homelessness through consistent access and education regarding breast health. The program sought to bring screening to women experiencing homelessness via mobile mammography and to establish structures of follow-up care for women with abnormal screening results.
A key element of the HOPE approach to follow-up care was connecting women with patient navigators within 1 week of screening to provide them access to care services. Understanding that multiple visits might be a challenge for this population, Shah and colleagues sought to achieve as much as possible in a single visit, making “a day of it” by including a check-in, a patient survey, the medical consult, and breast health education. A meal was offered in the middle of the process; when patients left, they received a gift bag, which included hygiene products, feminine care products, and another meal to go. To maximize the utility of the visit, patients were also offered a nurse practitioner consult, smoking cessation counseling, attention-deficit disorder counseling, colon cancer screening, primary care access, and even dental work.
The pilot program for HOPE was undertaken on a shoestring budget and included 9 screening events, which involved 124 screenings and a survey of 84 of the women screened. This information helped establish both demographics and attitudes of the population toward screening. Of those surveyed, nearly 62% were Black, 82% had previous history with a mammogram, 49% had a mammogram in the previous 3 years, and 38% had a family history of breast cancer. The survey further revealed generally positive patient attitudes toward screening, with relatively low percentages agreeing that certain issues were barriers to screening: fear of breast cancer (40%), lack of time for screening (7%), embarrassment related to having a mammogram (5%), and fear of pain from a mammogram (13%). These results indicated that the low rate of screening among women experiencing homelessness may be due more to access challenges than to lack of interest.
Shah described a high level of engagement in the pilot program, and he was happy to find the rate of breast cancer diagnosis was low. The success of the HOPE pilot study demonstrates that a low-cost program can improve health equity and be eagerly embraced by a difficult-to-reach, underserved patient population.
Kilic SS, Mayo ZS, Weleff J, et al. Breast cancer screening in persons experiencing homelessness. J Clin Oncol. 2022;40(suppl 16):6515. doi:10.1200/JCO.2022.40.16_
CHIRAG SHAH, MD
Professor of Radiation Oncology
Co-director, Comprehensive Breast Program
Director, Breast Radiation Oncology
Director, Clinical Research
Cleveland Clinic Cancer Center